The impact of accreditation on continuous quality improvement process in undergraduate medical education programs: A scoping review

Background Accreditation in medical education has existed for more than 100 years, yet the impact of accreditation remains inconclusive. Some studies have shown the effects of accreditation on student outcomes and educational processes at medical schools. However, evidence showing the impact of accreditation on continuous quality improvement of undergraduate medical education programs is still in its infancy. This scoping review explores the impact of accreditation on continuous quality improvement (CQI). Methods This scoping review followed the methodology of the Preferred Reporting Items of Systematic Reviews and the Meta-Analysis extension for scoping reviews (PRISMA-ScR) checklist outlined by Arksey and O'Malley (2005). Databases, including PubMed, Medline, ERIC, CINHAL, and Google Scholar, were searched to find articles from 2000 to 2022 related to the accreditation of undergraduate medical education programs and continuous quality improvement. Results A total of 35 full-text articles were reviewed, and ten articles met our inclusion criteria. The review of the full-text articles yielded four themes: Accreditation and its standards in general, Accreditation and its impact on student outcomes, Accreditation and its impact on medical school's educational processes, Accreditation and CQI. However, the literature evidence suggesting the impact of accreditation on CQI is minimal. The quality assurance approach is based on meeting the standards of accreditation. The quality improvement approach is based on striving for excellence. Literature suggests a requirement to move from student outcomes to CQI measures. CQI requires everyone in the organization to take responsibility and accountability, considering quality as the result of every single step or process and leaders supporting improvements in data collection and data analysis for quality improvement. Conclusions The literature on accreditation and CQI are limited in number. More research studies are required to enhance undergraduate medical education accreditation practices' value to medical students, educators, academic leaders, programs, and the public. It was recommended that medical schools embrace the culture and vision perpetuated by the CQI process.


Introduction
Accreditation is expected to ensure the quality assurance of higher education (Salto, 2018).According to the World Health Organization (WHO), regulatory bodies should play a central role in ensuring that public and private sector professionals are competent, sufficiently experienced, and adhere to agreed standards relative to the scope of practice and competency enshrined in regulation and legislative norms; countries should be supported in establishing or strengthening them to provide continuous updates to accreditation and credentialing (WHO, 2016, p. 20).
The WHO emphasized the importance of accreditation and regulation.But only 49% of countries have access to accreditation bodies that can accredit medical schools (Bedoll et al., 2021).van Zanten et al. (2012, p.587) defined accreditation as a "review of an educational program conducted by a governmental organization or a private entity accountable at a government level based on publicized standards and predetermined protocols."Medical education accreditation has existed for over 100 years (Akdemir et al., 2018;Loddenkemper et al., 2010).However, the evidence for the impact of accreditation and its outcomes is inconclusive (Acevedo-De-Los-Ríos & Rondinel-Oviedo, 2022;Blouin et al., 2018;Dattey et al., 2014;Volkwein et al., 2007).The literature regarding the impact of accreditation on medical schools' processes or quality improvement (QI) processes is still emerging, even though there are few articles on this topic.
The accreditation process is important as the citations/negative reports and site visits by the expert reviewers can bring curricular reforms and enhance the credibility of these programs (White et al., 2013).Accreditation can lead to a change process and impact medical schools' educational processes (Arja et al., 2021;Blouin et al., 2018).The accreditationrelated activities enable medical colleges to review and reassess their processes that improve medical education programs (Blouin et al., 2018).
It was identified that graduates from accredited medical schools are performing better in programs with Educational Commission for Foreign Medical Graduates (ECFMG) certification (Tackett et al., 2021;van Zanten, 2015).Thus, educational program quality appears to be directly related to student performance, suggesting that the accredited undergraduate medical education programs improved the quality of education offered to the students.Educational programs did benefit from engaging in the quality improvement processes (Tackett et al., 2021).The ECFMG announced that "for a medical school to achieve recognized accreditation status, the accrediting agency of the school must be reviewed and recognized by an external quality assurance organization.This quality assurance organization, in turn, must be reviewed and approved by ECFMG.Only medical schools accredited by an agency recognized by an organization approved by ECFMG will satisfy the requirements of the Recognized Accreditation Policy" (ECFMG, 2022).The announcement by ECFMG has further increased the importance of the accreditation of medical education programs.Also, there is an inherent belief that the accreditation of medical schools guarantees the quality of educational programs of medical schools.Despite the importance and emphasis on accreditation, there is no guarantee that it achieves the intended outcomes of accreditation and medical schools.Quality management aims to achieve accreditation goals through a variable blend of quality assurance (QA), QI, and quality control (Akdemir et al., 2018).
Continuous quality improvement (CQI), which originated in business as a method of quality control for services or products (Radawski, 1999), is an ongoing cycle of organizational improvement that uses quality indicators (Kritchevsky & Simmons, 1991).It is time to move from QA to QI across medical education programs (Barzansky et al., 2015).Barzansky et al. (2015) suggested having a periodic evaluation of programs in addition to the summative evaluations of the programs by accreditation bodies at fixed intervals.Barzansky et al. (2015) emphasized the importance of submitting annual reports by medical schools.The functional CQI process should be feasible to implement.It should focus on accreditation standards to improve the quality of educational programs and outcomes and avoid duplication of efforts (Barzansky et al., 2015).
In 2015, the Liaison Committee on Medical Education (LCME) began requiring internal CQI processes for medical programs to ensure compliance with accreditation standards (Stratton, 2019).LCME added the language to its standards: strategic planning and CQI, which states that a medical school must engage in ongoing planning and CQI processes that establish short-and long-term goals for the educational program, resulting in the achievement of measurable outcomes that are used to improve the quality of the educational program.This should ensure effective oversight of the educational program's compliance with accreditation standards (LCME, 2022, p. 1).
Regulatory and accreditation agencies view accreditation as a crucial instrument for meeting established standards and affirming higher education programs' legitimacy, status, and suitability.Conversely, some stakeholders perceive the accreditation process as a drain on resources and efforts, potentially outweighing its cost-effectiveness (Blouin et al., 2018;Simpson et al., 1998).Accreditation has enhanced various educational processes, including documentation, monitoring, data analysis

Amendments from Version 1
We added additional information in the second to last paragraph of the introduction section.This emphasizes the importance of this study and the need for further research in this unexplored area regarding the impact of accreditation on CQI.We added more information to the Search Strategy, eligibility criteria and selection of sources, and Data charting sections.I hope this helps the reader in understanding the search strategy.We added the missing information under the theme "Accreditation and its standards in general."We added more information to our results section.This could help the reader to understand the discussion in detail.We also elaborated conclusions section.
Any further responses from the reviewers can be found at the end of the article and governance (Arja et al., 2021;Blouin et al., 2018).However, there is no concrete evidence regarding the impact of accreditation on CQI.This scoping review explores the literature regarding the impact of accreditation on the CQI process in undergraduate medical programs.The scoping review maps pertinent literature about a topic of interest (Arksey & O'Malley, 2005).A scoping review is less likely to address a specific research question and even less likely to evaluate the quality of studies included in the scoping review (Arksey & O'Malley, 2005).The evidence about accreditation and CQI in medical education programs is still in its infancy (Akdemir et al., 2020).This led us to choose a scoping review over a systematic review to explore the impact of accreditation on the CQI process in undergraduate medical education programs.

Research protocol
We followed the scoping review framework, the Preferred Reporting Items of Systematic Reviews, and the Meta-Analysis extension for scoping reviews (PRISMA-ScR) checklist (Arksey & O'Malley, 2005;Tricco et al., 2018).It was summarized by the Joanna Briggs Institute (2015) as a six-stage approach to conducting the scoping review as outlined: 1. Identify the research question, 2. Identify relevant studies/literature, 3. Select the literature, 4. Chart the data, 5. Collate, summarize, and report results; and 6.Consult (optional) A scoping review has a broader scope than a systematic review (Arksey & O'Malley, 2005).The scoping review aims to identify the breadth of the current literature regarding the research question and identify knowledge gaps (Arksey & O'Malley, 2005).

Information sources and search strategy
We searched PubMed, Medline, ERIC, CINHAL and Google Scholar (2000 to present, in-process & other non-Indexed citations) to identify articles addressing the impact of accreditation on CQI process in undergraduate medical education programs.Search strategies were developed by an academic health science librarian (LN) with input from the project leads (SA) and co-leads (AT and JF).The search strategy and database selection were determined in consultation with an academic health science librarian (LN) Librarian and a researcher familiar with scoping review (AT).The search strategy included PEO questions examining the relationship between exposure and outcome, which are accreditation and CQI in our study.It also included the question related to exploring the scope of literature on Condition and Context, which is undergraduate medical education programs or medical schools in our study.The keywords used for the search were "quality improvement," "accreditation," "medical education," and "medical students."Please refer to Table 1.Searches were completed in December 2022 and limited to articles published between January 1, 2000, andOctober 31, 2022.The reason for selecting the year 2000 reflects the relevance of data in this topic.English-language limits applied to all databases, and any article retrieved in a language other than English was excluded.ii.Use each database's thesaurus to build a slightly different search strategy for each database.

Eligibility criteria and selection of sources
All abstracts were independently screened (by lead and co-lead, SA and JF).The articles resulting from the first database (Medline, PubMed, and ERIC), second database (CINAHL), and Google Scholar searches were screened for relevance by the principal investigator (SA).Another co-lead (JF) reviewed all abstracts, the same as the principal investigator.Both investigators screened titles and abstracts independently in a data sheet using Excel.A common consensus was required between SA and JF.If there was a disagreement, it was resolved by another co-lead (AT).At first, only titles and abstracts were reviewed.Only articles not excluded through the abstract review underwent full-text review.Primary research articles written in English were included if they: 1. Discussed the accreditation process for medical schools or undergraduate medical education programs.
2. Emphasized the impact of accreditation on the CQI process at medical schools or undergraduate medical programs.
3. Involved undergraduate medical programs and their basic medical education accreditation standards.

Ethical approval
This study was exempted from the research and ethics committee approval at Avalon University School of Medicine as this was a scoping review.

Results
The first database search, on PubMed, Medline, and ERIC resulted in 279 abstracts.Of these 279 abstracts, 31 required a review of full-text articles, and one was a repeat.We excluded 247 articles based on graduate medical education or QI curriculum for residents, related to medical care, healthcare not in English, etc. Out of the 31 articles mandated for full-text review, 17 articles were categorized under general articles on accreditation, based on standards of accreditation and recent trends of accreditation, three articles were based on the impact of accreditation on educational processes, one article was based on the impact of accreditation on student outcomes, and ten articles described accreditation and CQI.The second database CINHAL resulted in nine abstracts.Out of the nine abstracts, three were removed as they were repeated from PubMed, and one was removed as it was published in a language other than English.The other five were also excluded as they were related to graduate medical education, education in general, QI in general education, or healthcare.The third database, Google Scholar search, resulted in 19,000 abstracts.But we reviewed only the initial 75 abstracts as Google Scholar was not returning many useful articles for this scoping review or the research question.Out of 75, three were repeats from PubMed.The other 68 articles were excluded as they were unrelated to this scoping review or the research question.Only four articles from Google Scholar required fulltext review.They were related to accreditation and accreditation standards and had nothing to do with CQI.Only ten articles that described accreditation and CQI (PubMed) were included in the final review to answer the research question.
In summary, we reviewed 35 full-text articles.Out of 35 articles, 21 concerned accreditation and its standards, including recent trends in medical education accreditation; three articles were related to accreditation and its impact on medical school education processes, one was related to accreditation and its impact on student outcomes, and ten published articles concerning accreditation and CQI.We were able to review another four articles found while retrieving these 35 articles.Of these four articles, two concern accreditation and its standards in general, one related to accreditation and its impact on medical school education processes, and two related to accreditation and its impact on student outcomes.Please refer to Figure 1.
The ten articles included for full review concerning the accreditation and CQI are as follows.Medical schools should engage in interim review of their compliance with the accreditation standards of their country and act on the results in order to support a culture of continuous quality improvement (CQI).Integrating CQI methods into annual programs and institutional evaluation is critical (Stansfield et al., 2019).It is also time for medical schools to change their approach toward CQI.
In the execution of their QI visions, medical schools should spend resources on embedding CQI in the organization's culture (Blouin, 2019).The Plan-Do-Study-Act cycle was implemented in one of the studies for learning and improvement because continuous review of course content, outcomes, and evaluations is a process that identifies strengths, challenges, and opportunities for innovative steps for CQI to the curriculum (Ward et al., 2018).Establishing CQI 3D dashboards incorporating the CQI framework was innovative (Shroyer et al., 2016).

Discussion
We categorized the articles into four themes as follows: 1. Accreditation and its standards in general, 2. Accreditation and its impact on student outcomes, 3. Accreditation and its impact on medical school's educational processes, 4. Accreditation and CQI.
In addition to accreditation and CQI findings, we would like to describe the themes that illustrate the breadth of literature.

Accreditation and its standards in general
Concern about the quality of graduates and Undergraduate Medical Education (UME) is growing internationally (Tackett et al., 2019).Over 3,000 medical schools worldwide provide training and education to future physicians (Bedoll et al., 2021).This number is twice as many as there were twenty years ago.Over many decades, healthcare workers and physicians have been crossing borders, increasingly globalizing medical education (Allen et al., 2022;van Zanten et al., 2008).Assuring and improving the quality of education and training for future physicians is imperative in the best interest of the communities that these physicians serve, especially migrating physicians from one country to another for QA purposes (van Zanten et al., 2008).However, there needs to be more evidence to support existing medical schools' accreditation practices or to lead the innovation or improvement of undergraduate medical education programs or the QI process at medical schools (Tackett et al., 2019;van Zanten et al., 2008).Establishing new accreditation practices and improving existing ones should be based on data to ensure more efficient use of resources.However, the evidence related to UME accreditation and CQI has yet to be systematically summarized, and concerns remain that, despite the growing momentum to implement accreditation worldwide, evidence informing UME accreditation systems is limited (Tackett et al., 2019).

Accreditation and its impact on student outcomes
The publications on accreditation and student outcomes were

Underlying data
The data for this article consists of bibliographic references, which are included in the References section.

David Rojas
University of Toronto, Toronto, Ontario, Canada It's crucial for the author to incorporate references that are more closely tied to medical education, especially those pertaining to accreditation.While references from other fields can be informative, the primary aim of this article is to establish the current status of continuous quality improvement and accreditation in the context of medical education.Therefore, medical education references would be more appropriate and beneficial.
It would be beneficial for the author to revisit the articles from Van Zanten and Taccket 2021.These articles only show a moderate effect from those accredited schools, and also elaborate on all the cofounders and why the results are not conclusive.This should be clearly stated in the article.Moreover, the announcement of the ECFMG to only allow applications from those trainees who have graduated from accredited institutions (with the WFME stamp) changed over the last year.Now, that is no longer a requirement to apply for the ECFMG certification.
Reflecting this in the text will add value to the article.
There is also evidence that the accreditation process Does not trigger curricular reform.Please review [1] The discussion section of the article seems to cover a wide range of topics, not just the ones identified via the scoping review.While I understand the authors' intentions, this approach may pose some limitations regarding the reporting standard for scoping reviews.For instance, how did the authors select the information they are presenting in the discussion?If the article is about accreditation and continuous quality improvement processes, why start with the impact on "student outcomes and educational processes"?Are these the only articles that cover these topics?Were they also identified via the scoping review search?A more focused and structured approach could help address these questions.I would refrain from covering areas outside the focus of the scoping review or aim to create a better argument and offer a better explanation of why this information is being presented in the article.
Your research has the potential to significantly contribute to our understanding of the accreditation and CQI process.By structuring the discussion section around the main focus of the article, you can further enhance its impact and inspire further research in this Area.
One key element that needs to be added to the current manuscript is the overall analysis of the literature found.The authors have found 10 articles, and they do a good job of describing them.However, when the articles are analyzed together -what suggestions do we have?What is the learning from the 10 articles (learning is different from describing the articles)?This approach aligns more with what is expected at the end of a scoping review.Having a section dedicated to the overall learning from the literature found will add robustness to the approach presented here.
agencies are in the process of getting themselves accredited by the World Federation for Medical Education (WFME).Hence this article is timely and important.Accreditation plays an important role in initiating, maintaining, and strengthening CQI processes at institutions.My suggestions for further improvement are: Major comments: This section requires more description and explanation for readers to understand the strategies described.
Discussion section: The authors have not described theme 1 Accreditation and its standards in general, The themes could be described in greater detail and the authors' experiences can be incorporated.
What are the limitations of this scoping review?
Are the rationale for, and objectives of, the Systematic Review clearly stated?Yes Are sufficient details of the methods and analysis provided to allow replication by others?Yes Is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.

Are the conclusions drawn adequately supported by the results presented in the review? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Health professions education I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
i. Most databases do have a subject heading thesaurus in the top banner.

4.
Continue modifying search and harvesting keywords and MeSH until results are highly relevant to topic.a. Apply limits to search: date of study publication, age of participant, language of article, etc. Databases & Search Strategy Pubmed Two starting searches below: one broad excluding outcomes, and one focused including outcomes.A. Focused Search including outcomes ((undergraduate[Title/Abstract] AND ("medical school"[Title/Abstract] OR "medical education"[Title/Abstract]) OR ("Education, Medical"[MAJR] OR "Education, Medical, Undergraduate"[Mesh])) AND ("accreditation"[Title/Abstract] OR "Accreditation"[Mesh])) AND (("quality improvement"[Title/Abstract] OR CQI[Title/Abstract] OR "change management"[Title/Abstract]) OR ("Quality Improvement"[Mesh] OR "Change Management"[Mesh])) 279 results, no limits B. Broad Search excluding outcomes ((undergraduate[Title/Abstract] AND ("medical school"[Title/Abstract] OR "medical education"[Title/Abstract]) OR ("Education, Medical"[MAJR] OR "Education, Medical, Undergraduate"[Mesh])) AND ("accreditation"[Title/Abstract] OR "Accreditation"[Mesh])) Three Search Approaches Handout.docx 2. Mastering Keyword Searching async workshop (self-enroll) a. Refresher on Boolean searching in Advanced Search of Pubmed, other subject databases.3. PubMed Online Training from National Library of Medicine a. Quick tours in 1-3 mins; 60 min tutorials; 90-300 min online classes in how to search PubMed.4. Zotero.org<-free online reference manager; 2-click citations and references in Word or Google Docs.a. Zotero's own Help Documentation is easy to read, includes screenshots.b.Download 1) Zotero, and 2) Zotero Connector extension for your browser (Chrome, Safari, etc.).i. Zotero Connector = one-click add online sources (including both metadata and PDFs or HTML full text) to your Zotero library. 5. Zotero D2L async workshop (self-enroll) a. Short videos, short quizzes, light reading.Leads you through installation, setup, basic and advanced features.

Table 1 . Research consultation & Search strategy with Librarian Lindsey Nichols. Context AND Condition AND Population
were excluded if they discussed the QI curricula in postgraduate training or the implementation of ACGME guidelines for postgraduate training.All three investigators (SA, AT, and JF) discussed any discrepancies related to inclusion and exclusion.
The principal investigator (SA) and co-investigator (JF) read full-text articles, extracted data, and charted detailed information in an Excel standardized data extraction sheet.Another co-lead (AT) reviewed the data extraction sheet.Please refer to Table

Table 2 . Scoping review-summary of articles. First Author year Country Title of the article Study population Aim Methodology Outcome measures Results/conclusions
(Roy et al., 2020)Al-Eyadhy and Alenezi (2021), and Tackett  et al. (2021).There was a positive correlation between the accreditation cycle and students' performance on national examinations among Canadian medical schools(Roy et al., 2020).Al-Eyadhy and Alenezi (2021) found that accreditation cycles were associated with increased student satisfaction rates.The pre-accreditation phase activities and the self-study process are essential triggers for QI practices related to accreditation.Tackett et al. (2021).identified a significant association between the accreditation status of the medical school and ECFMG certification rates.This suggests that program quality, in terms of student performance, may benefit from engagement in QI processes.

expertise to confirm that it is of an acceptable scientific standard. Version 1
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 1 :
Search Strategy Approach & Lore